Performance & Leave Policy  

Clinical Performance Evaluation and Assessment

Resident performance is evaluated through direct and indirect observation by faculty and house staff as the residents perform their duties. The criteria used for these evaluations include cognitive and non-cognitive characteristics.

Clinical Competencies

The ACGME competencies help define the foundational skills that every practicing physician should possess. These competencies are critically important in the successful practice of medicine and provide the framework for evaluating the progress of residents through their training pathways. These competencies apply to all specialties and physicians. The six competencies are as follows:

  1. Patient Care: Residents must be able to provide patient care that is patient- and family-centered, compassionate, equitable, appropriate, and effective for the treatment of health problems and the promotion of health.  
  2. Medical Knowledge: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, including scientific inquiry, as well as the application of this knowledge to patient care 
  3. Systems-Based Practice: Residents must demonstrate competency in:
    • working effectively in various health care delivery settings and systems relevant to their clinical specialty;
    • coordinating patient care across the health care continuum and beyond as relevant to their clinical specialty. 
    • advocating for quality patient care and optimal patient care systems
    • participating in identifying system errors and implementing potential systems solutions
    • incorporating considerations of value, equity, cost awareness, delivery and payment, and risk-benefit analysis in patient and/or population-based care as appropriate
    • understanding health care finances and its impact on individual patients’ health decisions
    • using tools and techniques that promote patient safety and disclosure of patient safety events (real or simulated)
  4. Practice-Based Learning and Improvement: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. Residents must demonstrate competence in:
    • identifying strengths, deficiencies, and limits in one’s knowledge and expertise
    • setting learning and improvement goals
    • identifying and performing appropriate learning activities
    • systematically analyzing practice using quality improvement methods, including activities aimed at reducing health care disparities, and implementing changes with the goal of practice improvement
    • incorporating feedback and formative evaluation into daily practice
    • locating, appraising, and assimilating evidence from scientific studies related to their patients’ health problems
  5. Professionalism: Residents must demonstrate a commitment to professionalism and an adherence to ethical principles. Residents must demonstrate competence in:
    • compassion, integrity, and respect for others;
    • responsiveness to patient needs that supersedes self-interest
    • cultural humility
    • respect for patient privacy and autonomy
    • accountability to patients, society, and the profession
    • respect and responsiveness to diverse patient populations, including but not limited to diversity in gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation
    • ability to recognize and develop a plan for one’s own personal and professional well being
    • appropriately disclosing and addressing conflict or duality of interest
  6. Interpersonal and Communication Skills: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health. Residents must demontrate competence in:
    • communicating effectively with patients and patients’ families, as appropriate, across a broad range of socioeconomic circumstances, cultural backgrounds, and language capabilities, learning to engage interpretive services as required to provide appropriate care to each patient
    • communicating effectively with physicians, other health professionals, and health-related agencies
    • educating patients, patients’ families, students, other residents, and other health professionals
    • acting in a consultative role to other physicians and health professionals
    • maintaining comprehensive, timely, and legible health care records, if applicable
    • Residents must learn to communicate with patients and patients’ families to partner with them to assess their care goals, including, when appropriate, end-of life goals

Milestones

The ACMGE Surgery Milestones are a specialty-specific framework for evaluation of residents in general surgery programs. These were developed to provide a description of skills, knowledge, attitude, and behavior that encompass the growth of a surgical resident throughout training, from novice to expert. Each milestone is categorized under one of the 6 ACGME Competencies. There are 18 total General Surgery Milestones, describing traits from level 1-5. The levels were not meant to correlate with PGY level, and do not represent requirements for promotion for one level to the next.  However, the expectation is that interns entering residency should be at least at a level 1 for all milestones. 

Each Milestone has a description of levels that delineate competency from novice to expert. These descriptions are too long to list here, but are described in this document: https://www.acgme.org/globalassets/pdfs/milestones/surgerymilestones.pdf

The Surgery Milestone subcompetencies include the following:

Patient Care

            PC1: Patient Evaluation and Decision-making

            PC2: Intraoperative—Performance of Procedures

            PC3: Intraoperative—Technical Skills

            PC4: Postoperative patient care

Medical Knowledge

            MK1: Pathophysiology and Treatment

            MK2: Anatomy

Interpersonal and Communication Skills

            ICS1: Patient and Family-Centered Communication

            ICS2: Interprofessional and Team Communication

            ICS3: Communication within health care systems

Professionalism

            Prof1: Ethical Principles

            Prof2: Professional Behavior and Accountability

            Prof3: Administrative tasks

            Prof4: Self-Awareness and Help-seeking

Practice Based Learning and improvement

            PBLI1: Evidence-Based and Informed Practice

            PBLI2: Reflective Practice and Commitment to personal growth

Systems Based Practice

            SBP1: Patient Safety and Quality Improvement

            SBP2: System Navigation for Patient-Centered Care

            SBP3: Physician Role in Health Care Systems

Entrustable Professional Activities

Entrustable Professional Activities (EPAs) were developed to provide the opportunity for frequent, time-efficient, feedback-oriented and workplace-based assessment in the course of daily clinical workflow. EPAs are an important clinical assessment component of competency-based resident education (CBRE). They offer the opportunity to operationalize competency evaluation and related entrustment decisions in the course of regular patient care, and address some of the challenges educators and trainees have faced in bridging core competency theory into clinical practice and performance assessment.

It is important to note that EPAs are NOT competencies, but rather a complement to competencies, and serve as a way to translate the broad concept of competency into everyday practice

  • EPAs are units of work a physician performs that can be directly observed - things people do, such as evaluating and managing a patient experiencing a specific medical concern.
  • Competencies are broad and foundational domains of ability, such as medical knowledge or interpersonal skills.
  • Milestones are capabilities that describe progress at advancing levels of competence along the sequence from novice to expertise.

There are two types of EPA assessments:

  1.  Formative EPA microassessments: these are performed throughout the course of a rotation, either by faculty, fellows, or senior/chief residents of junior residents. These are on-the-fly, quick assessments of a residents entrustment level of a specific preoperative, intraoperative, or postoperative skill. The EPA microassessment forms are available through this link: https://app.smartsheet.com/b/form/d6f493cd12994946a2372c77cbe403bf?
  2. Summative EPA assessments: these are entrustment level decisions made by the Clinical Competency Committee for each resident on a semiannual basis, based on EPA microassessments, end-of-rotation evaluations, and other data considered by the committee

The General Surgery EPAs encompass the following areas (pre/intra/postoperative)

  1. RLQ pain/Appendicitis
  2. Benign or malignant breast disease
  3. Benign or malignant colon disease
  4. Gallbladder disease
  5. Inguinal hernia
  6. Abdominal wall hernia
  7. Acute abdomen
  8. Benign anorectal disease
  9. Small bowel obstruction
  10. Thyroid and parathyroid disease
  11. Dialysis access
  12. Soft tissue infection
  13. Cutaneous and subcutaneous neoplasms
  14. Severe acute or necrotizing pancreatitis
  15. Perioperative care of the critically ill surgery patient
  16. Flexible GI Endoscopy
  17. Evaluation/initial management of a trauma patient
  18. Provide general surgery consultation

Please click here for more information about EPAs

American Board of Surgery In-Training Exam (ABSITE)

The ABSITE is yearly standardized examination that is administered during the last weekend of January for all general surgery residents in ACGME accredited programs. It allows for assessment of surgical trainees’ medical and surgical knowledge and management of clinical problems. It allows for benchmarking of trainees by level relative to similar level trainees across the country. Importantly, testing is not only a mechanism of formative evaluation, but it helps with learning and growth. It provides a framework of topics that are in the scope of general surgery and stimulates reading and research, both before and after the actual examination. The content outline for the ABSITE is available here. 

As of 2025, the ABS will no longer report percentile scores by PGY year for the ABSITE. With this in mind, the UCSF General Surgery Residency program benchmarks for ABSITE scores by PGY year are as follows:

                % correct             3-digit

PGY1     60%                       400

PGY2     65%                       490

PGY3     70%                       545

PGY4     75%                       570

PGY5     75%                       570

An ABSITE score that is 50 points below the benchmark 3-digit score by PGY level will be considered a yellow flag and a score of 100 points below the benchmark 3-digit score will be considered a red flag. 

A yellow flag score requires a written remediation plan, identification of a faculty mentor, and requirement to take the ABSITE the following year (even if on vacation or overseas for research)

A red flag score will generate an automatic letter of concern, require a written remediation plan, identification of faculty member, requirement to take the ABSITE the following year (even if on vacation or overseas for research), as well as meeting with coaching provided via GME. 

All UCSF General Surgery categorical and preliminary residents are required to take the ABSITE yearly, during clinical and research years

The following reasons can be used to be excused from the ABSITE and must be approved by the program director in writing:

  1. Vacation
  2. Leave (medical, parental, family, personal, administrative)
  3. Illness (sick day)
  4. Overseas travel during research years

Any resident with a yellow or red flag score on the prior year must take the ABSITE the subsequent year, unless on formal leave. Vacation, research, travel, personal conflicts will not be accommodated in this setting. 

Evaluation Process

Each resident is reviewed on a semiannual basis by the Clinical Competency Committee (CCC), chaired by the Associate Program Director of Evaluation and Assessment, Dr. Lan Vu MD.  Members of the CCC include program leadership (Chair, PD, APD, VC for Education), Pat O’Sullivan, education leads of all rotations, and clinical advisors of the residents being discussed.  For a complete list of members and schedule of performance reviews, please click here. 

Information used to help inform performance review include:

  • End-of-rotation evaluations
  1. Performed by faculty service education lead, incorporating feedback from all faculty
  2. Peer evaluations (other residents/fellows on the service)
  3. Designated service APPs (if applicable)
  • EPA microassessments
  • Case logs
  • Grand Rounds/didactics/skills lab attendance records
  • ABSITE scores
  • TWIS quiz completion
  • Direct observations by committee members
  • Direct communications to program leadership
  • Medhub on-the-fly evaluations/confidential comments

Milestone levels are assigned for each resident for all 18 milestones. Areas for improvement or growth are noted. 

The results of the formal review and the summary evaluation will be provided to the resident as well as the resident's advisor. The advisor is responsible for discussing it with the resident. Digitally signed copies of the Summary Performance Review Sheet and the accompanying letter are included in resident personnel files in the Resident Education Office.

Promotion

Residents are appointed on a yearly basis. Residents whose performance meets the expected standards will be promoted to the next level of training.

Remediation and Administrative Actions

Please make a note of the UCSF housestaff information booklet which describes the formal UCSF GME Academic Due Process Policy. 

Remediation and Performance Improvement Plans

Probation

Probation is a conditional status that places specified requirements for improved performance on the resident, with dismissal from the residency as a possible result if the prescribed improvement does not occur. The requirements will be tailored to the individual situation, and they will prescribe the response expected of the resident and will include time limits for the probationary period. These requirements will be given to the resident in writing and discussed with the resident by his or her advisor, who must attend the CCC meeting when the resident is discussed. The resident is also required to speak directly with the Chair of the CCC. The performance of a resident on probation will be reviewed at least quarterly by the CCC, which may remove or extend probation and provide additional feedback to the resident and advisor. In general, residents will be expected to earn removal from probation within one or two quarters, but the maximum period of probation cannot exceed 8 consecutive quarters. At this point dismissal from the residency program would be likely unless there were compelling extenuating circumstances.

Dismissal

Although rare, dismissal from the residency program is a potential consequence of poor performance. Dismissal may follow a period of probation, or in exceptional circumstances, it may occur without a preliminary probationary period. Examples of events that may instigate dismissal without prior probation include criminal behavior and some types of substance abuse, dishonesty, or immoral behavior.

Substance Abuse: Although the Department of Surgery will not tolerate substance abuse among its residents, substance abuse will not necessarily result in dismissal. Each case will be considered on its own merits. Residents troubled by substance abuse will be referred to the University of California, Faculty and Staff Assistance Program. In some cases, the recommendation may be for suspension (with pay and benefits) until the outcome of therapy can be determined.

Appeal

The process for appeal of an adverse action such as remediation, probation or dismissal from the program is detailed in the Housestaff Handbook, and is available on the GME website. If an administrative action (suspension, probation, involuntary extension of training, non-renewal of contract, dismissal) is taken, the resident will be given written notification by the program director and given opportunity to appeal to the Vice Dean of Education.  

Vacation & Leave

  • GS Categorical PGY1: 1 1-month block of vacation as indicated. Because of difficulty with staffing during the December (block 6, 11/21-12/20) and January (block 7, 12/21-1/20) blocks (fewer moonlighters, APPs, preliminary intern interviews), no categorical intern is given vacation during these blocks
  • Preliminary PGY1: Are assigned 2 2-week blocks of vacation, one during either block 6 or 7 for residency interviews and the last two weeks of the year (6/6-6/20), to allow for transition to the next program. 
  • PGY-2 ,3, 4, & 5's: Four weeks of vacation, taken as two 2-week blocks

Parental Leave

Please see the Parenting in Surgery page for more details regarding parental leave. 

Sick Leave & Disability Leave

Each resident is entitled to use up to twelve (12) days per academic year for personal illness or disability. In addition, any remaining educational or vacation leave may be used to cover illness or disabilities, which exceed twelve (12) days of sick leave. Should a resident exhaust all paid time leaves (sick, educational, and vacation), the resident may be placed on an unpaid leave until the end of the illness or disability. The total length of the leave (paid and unpaid together) may not exceed four (4) calendar months unless expressly extended in writing by the Chair or Program Director with the Chair’s approval. Any sick leave balance does not carry over from year to year.

Leave of Absence

Any resident who required a leave of absence that exceeds one month in a calendar year, MAY be required to make up the lost time. If the leave of absence occurs prior to the research component of the training program, this additional time would be taken from the research allotment. If the leave of absence occurs durng the clinical training component of the program, this additional time would be added on at the end of the chief resident year. The decision to require makeup time will be individualized and will reflect the resident’s overall performance, case volume, ABS requirements, etc.

Resident Supervision

I. POLICY STATEMENT

The UCSF General Surgery residency program requires active supervision of all residents in the program by an appropriately credentialed Medical Staff member with the supervision documented in the medical record.

Every patient must have an identifiable, appropriately-credentialed and privileged attending physician who is responsible and accountable for that patient’s care. This information must be available to residents, fellows, faculty, other members of the health care team, and patients. Residents, fellows, and faculty must inform each patient of their respective roles in that patient’s care when providing direct patient care. This information must be available to residents, faculty members, other members of the health care team, and patients

Residents must be provided with prompt and reliable systems for communication with attending physicians.

II. REASON FOR POLICY

This policy describes specific supervision policies for residents in the general surgery residency program at UCSF. Per ACGME common program requirements, the program must ensure that all resident clinical activities be appropriately supervised, and that the appropriate levels of supervision are exercised in specific clinical settings.

These policies outline the minimum levels of supervision that are required, and the attending physician responsible for patient care must determine if a higher level of supervision is warranted on a case-by-case basis. This should be informed by an assessment of an individual resident’s clinical competency and level of training.

III. DEFINITIONS

  1. Direct Supervision: The supervising physician is physically present with the trainee during the key portions of the patient interaction; or, the supervising physician and/or patient is not physically present with the trainee and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.
  2. Indirect Supervision: The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.
  3. Oversight: The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

Supervising physician: 1) attending physician with credentials to perform the procedure or activity at the clinical site in question or 2) a surgical resident at the PGY2 level or higher whose supervision level is designated as “oversight”.

Resident: This policy applies to all clinical residents in the UCSF General Surgery Residency Program, including the following:

  • All categorical General Surgery Residents PGY1-5
  • Non-designated preliminary surgery residents PGY1-2
  • Designated preliminary PGY1 residents in OMFS, Ophthalmology, and Interventional Radiology

Faculty attending physician: A physician on the medical staff, credentialed in the procedure or activity at the clinical site where the procedure or activity is occurring.

IV. PROCEDURES

A. Principles

The attending physician is responsible for the care provided to individual patients. All residents function under the supervision of appropriately credentialed attending physicians.

Residents as individuals must be aware of their limitations. Failure to function within graduated levels of responsibility or to communicate significant patient care issues to the responsible attending physician may result in the removal of the resident from patient care activities.

PGY1 residents must initially be directly supervised until competency is obtained. This assessment will be informed by entrustable professional activity microassessments, rotation evaluations, skills lab evaluations, and direct observations by faculty, residents, and other providers.

All procedures performed in the operating room must be directly supervised by an attending physician for the key portions of the procedure

B. Competencies (Table of Procedures)

Below is a table of procedures indicating which procedure a surgical resident may perform, with and without supervision. In all cases, the clinical situation, the experience of the specific resident, the judgment of senior residents and attending physicians, will determine if a higher level of supervision is required.  

      PGY
Procedure  12345
airway management, stable/unstable, trauma      DS DS DS DS DS
anesthesia              
  local   DS O O O O
  field block   DS IS IS IS IS
  peripheral nerve block   DS IS IS IS IS
ankle-brachial index     DS/IS O O O O
arterial line (I/R)     DS DS DS IS IS
arthrocentesis              
  lower extremity   DS DS DS DS DS
  upper extremity   DS DS DS  DS DS
bladder (Foley) catheter (I/R)      DS/IS O O O O
bladder irrigation     DS/IS O O O O
blood gases (arterial)     DS/IS O O O O
bronchoscopy     DS DS DS DS DS
cardiopulmonary resuscitation               
  closed   DS DS DS DS DS
  open   DS DS DS DS DS
cardioversion     DS DS DS DS DS
cast/splint (Ap/R)              
  for fracture   DS DS DS DS DS
  for immobilization/protection   DS DS DS DS DS
central line (femoral/jugular/subclavian)               
    insert DS DS DS DS/IS DS/IS
    remove DS/IS IS IS IS IS
chest tube              
    insert DS DS IS IS IS
    remove DS/IS IS O O O
colonoscopy, with/without biopsy      DS DS DS DS DS
compartment pressure measurement      DS DS/IS IS IS IS
conscious sedation     DS DS DS DS DS
cricothyroidotomy     DS DS DS IS IS
cultures (urine/sputum/wound)      DS/IS O O O O
cutdown              
  venous             
    insert DS DS DS DS DS
    remove DS/IS IS IS IS IS
  arterial             
    insert DS DS DS DS DS
    remove DS/IS DS/IS DS/IS IS IS
defibrillation     DS DS IS IS IS
Doppler study              
  venous   DS/IS O O O O
  arterial   DS/IS O O O O
  graft/fistula   DS/IS O O O O
drug administration              
  intravenous   DS IS IS IS IS
  intra-arterial   DS DS DS DS DS
esophagogastroduodenoscopy (EGD)      DS  DS  DS DS DS
endotracheal suctioning      DS/IS IS IS IS IS
endotracheal/nasotracheal intubation      DS DS DS DS DS
gastric lavage     DS/IS IS IS IS IS
incision & drainage, abscess/fluid collection/cyst      DS DS/IS IS IS IS
laceration repair     DS/IS IS IS IS IS
laryngoscopy     DS DS DS DS DS
long intestinal tube (I/R)      DS/IS IS IS IS IS
lumbar puncture     DS DS DS DS DS
mediastinal tube              
    insert DS   DS DS DS DS
    remove DS/IS IS IS IS IS
nasal packing              
  anterior   DS DS DS DS DS
  posterior   DS DS DS DS DS
nasogastric tube (I/R)      DS/IS IS IS IS IS
pacemaker/pacer wires, transthoracic               
    insert DS  DS DS DS DS
    remove DS/IS IS IS IS IS
pacemaker/pacer wires, transvenous               
    insert DS DS DS DS DS
    remove DS DS DS DS DS
paracentesis/acute PD catheter      DS DS DS DS DS
Percutaneoue fine needle aspiration/drainage/biopsy for fluid collection, cyst, abscess, mass      DS/IS IS IS IS IS
Peripheral IV (I/R)     DS/IS IS IS IS IS
perform/interpret lab tests (spin Hct/do UA/EKG/      DS/IS IS IS IS IS
pericardiocentesis     DS DS DS DS DS
peritoneal lavage     DS DS DS DS DS
phlebotomy (including blood cultures)      DS/IS IS IS IS IS
pleurodesis     DS DS DS DS DS
rectal tube (I/R)     DS/IS IS IS IS IS
remove foreign body     DS DS DS IS IS
sclerosis, other (eg, seroma)      DS DS DS DS DS
sigmoidoscopy/anoscopy               
  with biopsy   DS DS DS DS DS
  without biospy   DS DS DS DS DS
sutures/staples (I/R)     DS/IS IS IS IS IS
thoracentesis     DS DS DS DS DS
thoracotomy, emergency      DS DS DS DS DS
tracheotomy     DS DS DS DS DS
wound dressing change/vac change      DS/IS O O O  O

Legend

DS = Direct Supervision  

IS = Indirect Supervision    

O = Oversight        

DS/IS = Direct supervision, until competency is achieved, then indirect supervision          

I = insertion          

R = removal

V. Site-Specific Guidelines

SF-VAMC

ZSFG

Kaiser Permanente

Mandatory Attending Notification Policy

Please refer to the When to Notify an Attending policy below for details

Parenting in Surgery

Please refer to the Parenting in Surgery page` for a full list of policies, guidelines, and resources. 

Resident Research and Funding  

Please visit Resident Research Objectives & Policies on the resident research website.

Moonlighting

I. PURPOSE

This document (updated December 2024) outlines the program moonlighting policy of the UCSF General Surgery Residency Program

II. BACKGROUND

The moonlighting system at UCSF was implemented to decompress work for clinical residents and ensure adherence to ACGME duty hour regulations. The moonlighting workforce consists of general surgery, vascular, plastic surgery, neurosurgery, and urology residents who are in their research years, as well as a number of other physicians outside of the residency program, with various backgrounds, all of whom have completed at least one year of surgical residency training. 

Prior to AY21-22, the departmental policy for moonlighting has restricted the moonlighting activities of clinical residents to only during vacation. Due to increased demand for moonlighters and a smaller workforce that can take shifts, interest has grown to allow clinical residents to moonlight. 

This document serves to delineate policies for moonlighting for both clinical and research residents in the department of surgery

III. DEFINITIONS

  • Internal moonlighting is defined as extra work for extra pay performed at a site that participates in the residents’ training program.
  • External moonlighting is defined as work for pay performed at a site that does not participate in the residents’ training program.
  • “Clinical residents” are general surgery residents who are in their clinical years of general surgery residency. These residents are active on the ACGME roster and are subject to the requirements and regulations governing all ACGME-accredited training programs. 
  • “Research residents” are surgical residents who are in their dedicated research time and are designated as inactive on the ACGME roster. 

IV. PRINCIPLES

  • All moonlighting is voluntary.
  • The moonlighting system was originally implemented to allow research residents to decompress the work of clinical residents and to improve compliance with the ACGME duty hour regulations. Moonlighting by clinical residents should not compromise their ability to comply with these duty hour regulations
  • Moonlighting by clinical residents cannot interfere with the patient care obligations or educational activities of the clinical resident’s assigned service. 
  • Each rotation must have clear expectations for service obligations, weekend coverage, and overnight call that is expected for all residents on the service. These obligations must comply with ACGME duty hour regulations. Clinical duties within the scope of the expectations of the rotation are not eligible for compensation as a moonlighter. 
  • Clinical residents are not allowed to participate in external moonlighting
  • External and internal moonlighting is allowed for research residents
  • All moonlighting is prohibited during designated family or medical leave periods, per UCSF HR policy. This does not include time designated as vacation.

V. POLICIES

  • Internal Moonlighting (all):
    • Internal moonlighting must be supervised by faculty and is not to exceed the level of clinical activity currently approved for the trainee.
    • All moonlighters (clinical residents, research residents, and other physicians) must be approved by one of the moonlighting faculty leads (Dr. K. Hirose and C. Gomez-Sanchez), after appropriate evaluation and/or interview as needed. 
    • Moonlighters will be approved for specific services as deemed appropriate by the moonlighting faculty leads
    • Performance concerns by any moonlighter should be forwarded to the moonlighting faculty leads for further action
    • Moonlighters at the SFVAMC and at Kaiser are subject to those respective institutions’ credentialing processes and policies.
  • Internal moonlighting for Clinical Residents
    • Clinical residents who wish to moonlight during clinical time must have the written approval of the service education lead of their current rotation, in addition to the program director.  Each moonlighting shift must be approved.
    • Clinical residents’ moonlighting shifts must not interfere with the patient care and educational obligations to their assigned clinical service. 
    • Clinical residents who wish to moonlight during vacation must have the written approval of the program director. This approval will apply for the duration of the vacation block. Duty hours must be recorded for these shifts and must comply with ACGME regulations.
    • Clinical residents must record duty hours in Medhub and when combined with the normal work hours, must be below 72 hours for the week and ensure one day off per week (Sun-Sat)
    • Clinical residents may moonlight on the service they are currently assigned to with approval of the service education lead and program director, and only at a level below their current training level, for example the KTU R3 may moonlight as the KTU R1, but the Trauma R4 may not moonlight as the Trauma R4. 
    • These policies are subject to change in the event of 1) increases in duty hour violations 2) ACGME survey results showing a high rate of non-compliance with duty hour rules 3) ACGME citation for duty hours
    • These policies apply only to moonlighting shifts at UCSF sites and SFGH. 
  • External Moonlighting: External moonlighting is allowed only during residents’ dedicated research time. This activity is not covered under the University’s professional liability insurance program as this activity is outside the scope of University employment. The trainee will be responsible for his/her own professional liability coverage and any requirements for clinical privileging at the employment site.
  • Eligibility
    • Trainees on H1B or J1 visas are not allowed to moonlight.
    • PGY1 trainees are not allowed to moonlight
    • Trainees must have a full California medical license in order to moonlight
    • No clinical residents assigned to rotations at the SFVAMC may moonlight

VI. PROCEDURES

1. A trainee must have written pre-approval from the Program Director if he/she wishes to moonlight. Trainees must use the internal and/or external moonlighting form depending upon the type of moonlighting he/she wishes to do.

2. A clinical trainee who is moonlighting must track and record those days and hours in MedHub work hour tracking system regardless if the moonlighting is internal or external.

3. If excessive fatigue or performance issues are noted by the trainee’s supervisors and confirmed by the Program Director and moonlighting is felt to be a contributing factor to the fatigue, permission for moonlighting will be withdrawn.

4. Violations of the Moonlighting Policy may lead to Departmental disciplinary action.

VII. SCOPE

The Department of Surgery policy applies to all department residents during their rotations at any of the teaching sites (UCSF Health (Parnasssus, Mission Bay, Mt. Zion), Zuckerberg San Francisco General Hospital, San Francisco Veterans Affairs Medical Center, Kaiser Hospital, and California Pacific Medical Center).

Addendum

Specific scenarios

  • Unexpected absences

In the setting of a categorical/preliminary GS resident, plastics resident, vascular 0/5 resident not being available to work on general surgery service due to unexpected absence, e.g. fatigue, illness, family emergency, etc, the jeopardy resident will be available to fill in for this absence. 

In the setting of an advanced practice provider not being available to work due to an unexpected absence, the service must make arrangements to accommodate this deficiency. The shift may be offered as a moonlighting shift, but if unfilled, the jeopardy resident will not be used to fill this deficiency

  • Expected absences

Planned resident absences beyond the usual allotment of days off for the rotation must be approved by the administrative chief residents and program director. These days off must be requested in advance in order for the call schedule to be planned. 

Expected staffing deficiencies due to advanced practice providers (e.g. vacation, parental leave, unfilled positions, etc), will be offered up as moonlighting shifts but cannot be guaranteed to be filled beyond the allotment for that service per month. Other deficiencies must be made up by modification of schedules by the providers on the service. 

Additional Links:

Resident Book Reimbursement Program

All categorical general surgery and plastic surgery residents PGY1 and above are eligible to receive $200 in education fund reimbursement thanks to UCSF surgery alumni and faculty donations. The following items are applicable: educational books, software, journal subscriptions and D/Surgery laparoscopic training boxes. Items not clearly falling into one of those categories must be approved by the Education Office.

Turn original receipts and/or bank statements into the Education Office for reimbursement. Please allow 3-6 weeks for reimbursement processing.

Additionally, The City & County of San Francisco, in cooperation with CIR, administers Educational Expense Reimbursement requests of up to $600 per year from the Patient Care fund. Only residents scheduled for three or more months (12 weeks, not including vacation) in a fiscal year (e.g., July 1-June 30) are eligible to submit a reimbursement request.

More information and instructions to submit a reimbursement request can be found at https://sfdhr.org/online-tuition-reimbursement-process-zsfg-interns-residents

Please note that the education fund is a fixed amount every year. They process reimbursements in the order that they are received, and it’s possible that the fund will be depleted before every eligible person applies for reimbursement.

UCSF Resident & Clinical Fellow Meal Program

Residents on duty have access to food services 24 hours/day at all institutions.

Parnassus, Mission Bay, and Mount Zion

UCSF Medical Center supports eligible residents and clinical fellows by offering meals when working in the hospital at UC Moffitt/Long, Mission Bay and Mount Zion sites. Electronic meal cards (FastPay program) are distributed to each individual resident and funds allocated based on call schedules. Funds for the upcoming month are available for use on the first day of the eligible rotation. The FastPay cards can be used at select locations on Parnassus, Mission Bay, Mount Zion, Laurel Heights, and Mission Center campuses. To view the list of approved locations, please refer here. Lost or Stolen cards must be reported to the Surgery Education Office immediately by calling (415) 476-1239. Residents are responsible for paying the difference at the cashier, should purchases exceed the monthly card limit.  Funds do not roll over from month to month. All unused funds are revoked each month. All ACGME residents and fellows will be funded $350 a month when rotating at UC Medical Center (Parnassus, Mission Bay or Mt. Zion) on the GENERAL SURGERY rotations listed below:

  • MB Breast
  • MB HBP-GISS
  • MB Gold/Scope
  • MB OHNS
  • MB Peds
  • MZ Endocrine
  • UC Cardiac
  • UC Complex General Surgery
  • UC Critical Care
  • UC KTU
  • UC LTU
  • UC On Call-LTU
  • UC MBF (Dunphy)
  • UC Plastic
  • UC ACS
  • UC Debas
  • UC Thoracic
  • UC Vascular

Meal Card Program Guidelines:

  1. Money will be available on the first day of each rotation.
  2. Money is prorated if the rotation is split with another site or vacation
  3. Unused meal money will not be carried over after your last day on the rotation.
  4. Unused balances will be revoked after your last day on the rotation.

ZSFG

All ACGME residents and fellows performing clinical rotations at ZSFG are issued a meal card. Each card has a daily balance of $23.00 which breaks down to $5.00 for Breakfast and $9.00 each for Lunch and Dinner. Residents are responsible for monitoring their spending and are responsible for paying the difference if they exceed their maximum daily balance.

Residents and fellows are responsible for replacing lost, stolen, or misplaced meal cards. To obtain a replacement, residents should go to the Food & Nutrition Services Office (Bldg 5, 2nd Flr, Rm. 2D1A) with a Check or Money Order for $15.00 to get a replacement card. Checks should be payable to 'ZSFG.'

Veterans’ Administration Medical Center

The VA has a cafeteria that is open Monday thru Friday from 7 am-4 pm. For residents staying for overnight call, there is a meal program utilizing delivery from several participating outside restaurants. Vouchers are available from the service administrator. Tickets for breakfasts in the cafeteria are also provided to post call residents.

UCSF Physician Well Being Programs

Housestaff have access to a variety of systems for supportive intervention for dependency treatment and to obtain counseling services for a broad range of personal problems (e.g., workplace stress, anxiety management, personal or work relationships, depression, grief and loss, caregiver concerns, etc)

  • The UCSF GME has an extensive list of well-being and mental health resources for residents and fellows. The Map of GME Well-being Resources provides an easy to use guide to navigate all resource options.
  • The Faculty & Staff Assistance Program (FSAP) provides voluntary, free, and confidential services that include individual counseling and referral services at multiple locations. To set up an appointment, call 415-476-8279 or email FSAP@hr.ucsf.edu.
  • The UCSF Physician Well-Being Committee is dedicated to recognizing and offering assistance to staff and physicians who have problems with substance abuse or physical and mental illness which impair their ability to practice safely and effectively. Confidentiality will be assured if possible, depending upon the severity of the situation and the immediate risk to patient safety. If you are anxious about making the first call, you may contact the committee initially, just to learn more about how the committee can offer help. To contact the Physician Well-Being Committee Chair, call the Medical Staff Office: (415) 885-7268 
  • Physicians' Confidential Assistance Line (California Medical Association)
  • UCSF GME ProtoCall Services provides 24/7 urgent (not emergent) psychiatric care: (885) 221-0598.
  • Resident and fellow HMO and PPO health insurance plans cover virtual and in-person mental healthcare with an insurance co-pay. See the Urgent and Important Mental Health Services section of the GME well-being page for details.
  • Ginger is an app that offers confidential, on-demand emotional and mental health support for life challenges through coaching via text-based chats, self-guided activities, and video-based therapy and psychiatry. 

These and other options are described on the GME website. In addition, the Dean's Office is currently exploring additional well-being programs. Housestaff are urged to provide input to the Director of Graduate Medical Education or the Associate Dean for Graduate Medical Education.

Workhour Policy / Fatigue Monitoring

Definitions

  1. Work hours are defined as that time spent in all clinical and academic activities related to the training program. This includes all aspects of patient care in both the inpatient and outpatient settings, as well as all procedural activities in the operating room. It also includes time spent in the administrative aspects of patient care, the time spent transferring patient care (rounds), time spent in-house during assigned call and time spent in educational activities such as Grand Rounds, Resident Conferences and Surgical Skills Lab sessions. Time spent reading and studying off-site and practicing in the Skills Lab outside of scheduled training sessions is not included in work hours.
  2. In-house call is defined as that interval when the resident is required to be immediately available in the assigned institution.
  3. Call from home is defined as that interval when the resident is required to be available to return to the assigned institution within a reasonable period of time, but does not need to remain in the assigned institution.
  4. A day is defined as a continuous 24-hour period.
  5. A new patient is defined as one who has not previously received care from the surgery department.
  6. These definitions apply to all of the integrated and affiliated sites participating in the UCSF General Surgery Residency Training Program.

Policy

The program will ensure compliance with ACGME work hours regulations, as outlined below:

  1. Residents will work no more than 80 hours per week, averaged over a four-week interval.
  2. Residents will have one day in seven free of all educational and clinical responsibilities, averaged over a four-week interval.
  3. Residents will be assigned to in-house call no more often than every third night, averaged over a four-week interval.
  4. Following a 24-hour work session, residents will work no more than four additional hours.  Activities during the additional four hours may include didactic activities, maintaining continuity of patient care, transferring patient care, operating on patients—including the first operation of the day or an operation on a patient admitted during the 24-hour tour of duty. The resident may not have primary responsibility for the care of any new patient during this additional 4- hour interval.
  5. Call taken from home is NOT subject to the every third night limitation. However, when residents taking call from home return to the hospital for some indicated clinical activity, the hours spent in that clinical activity will count in the 80-hour limit. Additionally the frequency of call from home shall NOT prevent reasonable rest and personal time and shall NOT prevent one day in seven free from all educational and clinical responsibilities (see B.2. above).
  6. Residents should have an 8-hour time period between assigned work sessions.
  7. In unusual circumstances, residents may stay beyond these limits to care for a single patient. All such exceptions must be reported to the Program Director.
  8. Residents in the clinical years of the UCSF General Surgery Residency Training Program MAY NOT moonlight, except during vacations with written permission from the Program Director. Residents in the laboratory years MAY moonlight.

Workhours Monitoring

  1. All residents will enter their work hours weekly in MedHub. Residents must submit timesheets by 9:00am every Monday. 
  2. Residents have the option to use ResQ to automatically log hours to MedHub; ResQ users must still review their MedHub timesheets on a weekly basis to ensure accuracy, correct errors, and submit by 9:00am every Monday.
  3. Work hours monitoring includes the following :
    1. mid-month checks by the Education Office to identify residents at risk for violating work hours;
    2. schedule intervention/adjustment by the administrative chiefs (when applicable) or the service to ensure appropriate time off is given to avoid a violation. 
  4. Residents should have eight hours free of duty between scheduled duty periods.
  5. Residents must have at least 14 hours free of duty after 24 hours of in-house duty.
  6. Failure to submit a timely report may result in the residents being relieved of duty from that service until the report is received.
  7. Residents are expected to log hours accurately according to actual hours worked (not just scheduled shifts.)

Stress and Fatigue Monitoring

Faculty and residents will be instructed to recognize the signs of fatigue by annual review of the American Academy of Sleep Medicine “Sleep, Alertness and Fatigue Education in Residency (SAFER)" module. See Department of Surgery Workhours Policy/Fatigue Monitoring.

Residents are in close contact with faculty each day, which allows faculty to assess residents for signs of fatigue by direct observation.

If resident fatigue is present and action is needed, the resident will be sent home or sent to sleep and resume clinical duties when rested.

Fatigue Module Attestation ("Sleep, Alertness, and Fatigue Education In Residency" by American Academy of Sleep Medicine)

Impairment Module ("Doctors and Addiction: Helping Good People with a Bad Disease")

The EmergenTree outlines communication for any critical resident staffing issue (fatigue, illness, emergency, unexpected absence, etc.) 

Policy Deviations

  1. Deviations from the workhours policy are to be reported to the Residency Office, any faculty member, the faculty mentor for any involved resident, any of the resident members of the Departmental Resident Council, any member (faculty or resident) of the Departmental Education Committee, the Program Director, or the Chair.
  2. In addition deviations can be reported to any member of the institutional Graduate Medical Education Committee (resident member or faculty member), to the Graduate Medical Education office or to the UCSF Duty Hours Compliance Officer. Reporting to the GME Office can be totally anonymous if desired by calling 502-9400.
  3. Department of Surgery Faculty ombudspeople are designated at each rotation/hospital site (as listed below) to discuss any issues of concern (confidentially if desired and possible). The goal is to provide residents with a convenient channel of communication where they are working and ensure they always have the ability to raise concerns/questions even if they do not have quick access to program leadership (or do not feel comfortable raising concerns directly with program leadership).
  4. In addition, policy deviations or concerns can be reported to any member of the institutional Graduate Medical Education Committee (resident member or faculty member), to any member of the Graduate Medical Education office. Reporting to the GME Office can be done anonymously by calling the UCSF GME Confidential Hotline/Helpline at (415) 502-9400.
  5. The UCSF GME well-being and mental health resources page contains a comprehensive list of avenues to report concerns, either confidentially or anonymously, depending on the situation.

Weekly Conferences - Attendance Policy

Surgery Grand Rounds & M&M Conferences

Policy: In person or virtual attendance (minimum 75%) is required for all categorical and preliminary general surgery residents. Residents on vacation are excused from attending. Residents must sign in to claim credit.

Resident Conference Series

Policy: PGY1 - PGY5 surgical residents are required to attend a minimum of 75% of the sessions. This includes ALL general surgery, categorical and preliminary. Attendance is closely monitored. Residents on vacation are excused from attending. Residents must sign in to claim credit. Categorical interns from other specialties are welcome to attend.

Skills Lab

Policy: Attendance is required for all PGY1, PGY2 and PGY3 residents, approximately every other week, or as scheduled, by the Surgical Skills Center Director. Refer to the Surgical Skills Center website for the current schedule.  Residents on vacation are excused from attending.

Travel Reimbursement Policy

Request for Travel Reimbursement Form

Overview

The Department encourages residents to submit their clinical and basic science research efforts to significant scientific and surgical meetings for presentation. The Department will endeavor to help fund travel for categorical general, plastic, and vascular surgery residents who are presenting authors of abstracts accepted for oral/podium presentation, providing certain provisions and expectations are met.

Department Commitment

The Department will sponsor categorical general, plastic and vascular surgery residents to attend scientific and surgical meetings where the resident has submitted a first-author abstract that was accepted for an oral/podium presentation. This commitment will cover travel expenses of up to $1,500 per trip and $7,500/resident in total for their entire residency and will be limited to no more than two trips/year during the clinical years. The Department will not provide reimbursement for a resident to attend a meeting for a poster presentation.

The Department will consider requests for travel support for non-designated preliminary residents in the general surgery track for first-author oral/podium presentations on a case-by-case basis.

The Department strongly encourages residents to participate in at least one oral/podium presentation at the Academic Surgical Congress (of the Association for Academic Surgery and Society of University Surgeons), American College of Surgeons Clinical Congress, and/or the Pacific Coast Surgical Association per research year. In addition, the Department will sponsor up to two trips to attend professional development courses as part of the overall travel budget ($1,500/ trip and $7,500/ resident total). Trips during research years must be reviewed and approved by the research mentor, in addition to meeting budget requirements. If the resident has travel support/funding through their mentor, lab, or research award (e.g. T32, professional society award), then those monies should be used first rather than application to the Department.

Specific Guidelines & Limits: Travel assistance is a privilege, not a given. We need residents to be good stewards of the Department's resources, and to meet the Department at least halfway in using common sense and cost saving measures. All travelers are expected to exercise good judgment on behalf of the Department and follow UCSF policies and procedures. 

For reimbursement purposes, requests and notification for meetings and travel need to be approved in advance (via the Resident Travel Reimbursement Request form) by both the Residency Program Director and the Department’s Vice-Chair of Research. It is expected that each resident will work together with their mentor and the Vice-Chair to assure that there is appropriate stewardship and planning that goes into planning research-related travel.

Pre-travel approval is required prior to the booking of any travel expenses. Travel expenses made prior to approval are the financial responsibility of the traveler and may not be reimbursed.

Obtaining Pre-Travel Approval: To obtain approval for department-supported travel, residents must submit the Resident Travel Reimbursement Request form for each potential trip at least 90 days prior to the conference/meeting. Each submission will be reviewed; residents will be individually notified regarding travel approval and given instructions for submitting receipts for reimbursement.

Clinical residents must obtain approval for potential absences directly from their clinical service prior to submitting the Resident Travel Reimbursement Request form; clinical residents on general surgery rotations must obtain approval from the General Surgery Administrative Chief residents. Research residents are expected to obtain approval from their research mentor(s).

Please contact the Education Office if you have any questions regarding compliance with ACGME and ABS time in training policies and requirements.

Flight: Connexxus must be used to book flights. Only the cost of coach/economy class will be reimbursed; airline travel upgrades are considered a personal expense and are not reimbursable expenses. Flight changes must be approved before any change is made.

Hotel: The conference website or hotel block may be used to book a room, or by some other reasonable means. Reimbursement for hotel expenses will be subject to UCSF limits (currently $275/night before taxes). The hotel folio (bill) must reflect a $0 balance and include the last four digits of the credit card used to pay. If there are in-room meal/mini bar charges, itemized receipts must be provided. The proof of payment will be the hotel folio itself.

Registration: Registration fees for the conference should be paid by the traveler with a personal credit card after receiving pre-travel approval.

Rental Car: Most of the time, it is more economical to use shared rides, taxi cabs, and public transportation rather than a rental car for professional travel. Automobile rental will not be reimbursed without clear justification (before the trip) of the need for a rental instead of another mode of transportation. Keep in mind that fuel tax and insurance will not be reimbursed.

Meals: Meal reimbursement is based on actual expenses and should not exceed UCSF's daily per-diem of $79/day. Original, itemized receipts and proof of payment must accompany any request for reimbursement for meals.

Miscellaneous: Entertainment, health club expenses, video rentals, valet parking, and tips and not allowable and thus will not be reimbursed.

Reimbursement Process: All receipts (including Connexxus receipts for flights) must be submitted after pre-travel approval is obtained. Requests for reimbursement for travel should be submitted no later than 45 days of return from travel. Reimbursements for travel will be reported as taxable income if they are not finalized and approved within 60 days of return from travel.

When to Notify an Attending Policy

For All UCSF Surgical Housestaff

Call an Attending directly (or positively ascertain that an Attending has been notified) upon the following situations:

  • Death (even if expected)
  • Cardiac arrest
  • Respiratory failure either requiring intubation or significantly increased O2 demands
  • Severe respiratory distress
  • Airway issues
  • Transfer to ICU or higher level of care
  • Concern that patient needs a procedure or operation
  • A new need for acute dialysis
  • Bleeding requiring transfusion
  • Hypotension/hemodynamic instability
  • Symptomatic and severe hypertension
  • Significant new arrythmia
  • Suspected MI
  • Suspected PE
  • New onset severe chest pain
  • New onset severe abdominal pain
  • Abrupt deterioration in neurologic exam or profound decreased mental status
  • Significant change in neurovascular exam of extremity
  • Patient or family wishes to speak to the attending
  • Patient wishes to be discharged AMA

And In addition

  • Any other significant change in clinical status of patient that is of major concern.
  • Any new admission.
  • The arrival of a patient accepted in transfer from another institution.

Service specific criteria, e.g.

  • KTU: abrupt loss of urine output in recent kidney transplant pt that was previously making urine; ultrasound showing vascular/ureteral problem.
  • LTU: ultrasound showing absence of hepatic arterial flow
  • VASCULAR: loss of a pulse or Doppler signal that was present earlier
  • PLASTICS: abrupt change in signal /duskiness of free flap

EmergenTree

The EmergenTree - outlines communication for any critical resident staffing issue (fatigue, illness, emergency, unexpected absence, etc.) 

Jury Duty

If you are called for jury duty, the Education Office can provide a letter to the court requesting that you be excused from jury duty. Please request your jury duty letter from the education office as soon as possible after you receive your summons and include the court address listed on your summons. The Education Office will prepare and send the letter to you within 1-2 business days. It is then your responsibility to follow the instructions provided on your summons for submitting the letter to the court and requesting an excusal from jury duty.